Child Death Review Working Group
Expert community committed to examine systems responding to unexplained child death investigations.
About the Child Death Review Working Group
Child Death Review is the multi-professional and multi-disciplinary process by which child deaths are scrutinised in detail to identify causes, risks, potentially modifiable factors and learning, to enable effective prevention of future deaths. Child Death Review should ensure consistency and quality of investigation of deaths and support for families always keeping the best interests of children at the centre of the process.
The range of professionals involved in Child Death Review includes but is not limited to paediatricians, family health, pathologists, nurses, police, forensics, child welfare, emergency responders, mental health, education and public health.
Child Death Review follows a socio-ecological framework and considers factors and learning from any relevant domain, including but not limited to intrinsic vulnerabilities, physical environment, family and parenting environment, and provision of healthcare and other services.
Child death review may contribute to improvements in child death investigations and raise the quality of information collected.
Our Mission:
Welcoming all sectors and professionals interested in the investigations and health assessments tied to unexplained child deaths. This public health system of review in many countries involves collaboration and has historically helped to identify critical new issues like Shaken Baby Syndrome, MbP, and many other types of abuse.
Shape the future of the Child Death Review Working Group
Join us online in this discussion forum or in person when this group meets at ISPCAN Congresses to learn and share from various experts in a range of countries on how to establish a system of review or improve the current systems in your regions.
Why Join the Child Death Review Working Group?
Global Connections
Network with child death review experts, and mentors worldwide.
Child Death Review Guidelines
Access to data driven effective child death review programs.
Career Advancement
Opportunities to present your work at ISPCAN congresses and virtually.
Cutting-Edge Research
Work alongside world-renowned experts to make an impact in this critical area.
Collaborate & Innovate
Learn from others and work on global projects, research, and advocacy initiatives.
Support for Child Protection Professionals
Get the expertise and support you need to address burnout and fatigue among child death review professionals
Get Involved
How to get involved in the Child Death Review Working Group
Sign up for an ISPCAN Membership
Connect with the Child Death Review Working Group on the member portal
Subscribe to the ISPCAN Newsletter and discussions in the member portal
Join the discussion, start connecting & grow your career!
Who Can Join?
Child Death Review (CDR) is a systematic process aimed at examining child fatalities to identify causes and implement preventive measures to enhance child safety and health. This working group is a community of practice shared learning for members to connect and build lines of communication with one another, share ideas, skills, research, resources, multiple perspectives, and new information regarding this topic.
If you are a child death review expert or have an interest in learning more about this critical topic, then please join us for the latest cutting-edge research and practice in this area, please consider joining us. The Child Death Review Working group is open to active ISPCAN members only.
Current Projects
Join us in Melbourne
At the ISPCAN Congresses, the Working Group will share case study presentations and discussion with international multi-sectoral group to examine systems responding to unexplained child death investigations. Join this free pre-congress half day workshop being held before the congress.
Methodology Data Collection: Information is gathered from various sources, including medical records, police reports, and family interviews, to create a comprehensive picture of each case. Multidisciplinary Teams: CDR teams typically consist of professionals from diverse fields who collaborate to review cases and discuss findings. Review Meetings: Regular meetings are held to discuss individual cases, identify common themes, and develop recommendations for prevention strategies.
Critical Data and Events
Death review is a means of documenting the causes of a death and the factors that contributed to it, identifying factors that could be modified and actions that could prevent future deaths
The National Child Mortality Database
The National Child Mortality Database (NCMD) is an NHS-funded programme delivered by the University of Bristol. We gather information on all children who die in England, so that we can improve and save children’s lives in the future.
The National Center for Fatality Review and Prevention
Access critical open access resources. By learning together, we strengthen our collective capacity to unlock lessons from preventable deaths.
Child Death Review Objectives
• Identify Causes: CDR aims to uncover the underlying causes of child deaths, including medical, social, and environmental factors.
• Prevent Future Deaths: By analyzing trends and patterns, CDR seeks to implement preventive measures that can reduce the risk of similar fatalities in the future.
• Enhance Community Awareness: CDR processes help raise awareness about child safety issues and promote community engagement in prevention efforts
• Policy Development: Findings from CDR can inform policy changes and resource allocation to better protect children and support families.
Child Death Review is a vital process that not only seeks to understand the tragic loss of children but also aims to foster a safer environment for future generations. By learning from each case, communities can work together to implement effective strategies that protect children and promote their well-being.
Related Resources
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Access cutting-edge resources using the links below
Supporting Downloads
American Academy of Pediatrics Policy Statement Child Fatality Review 2024
Comparing types of child fatality review in the U.S - Vincent J. Palusci
Needs and experiences of families after a sudden unexplained death in childhood: a qualitative study. Emily Cooper , Jonathan Holmes, Nikki Speed, Joanna Jane Garstang
Developing a toolkit to support parents’ involvement in child death review: an experience-based co-design study - Joanna Jane Garstang,Jenna Spry, Gayle Routledge, Anna Pease, Karen L Shaw, Sara Kenyon
Child death review: understanding variations in practice using normalisation process theory - Karen Shaw , Sara Kenyon , Anna Pease , Jenna Spry , Gayle Routledge , Joanna Jane Garstang
Family Involvement in Learning From Expected Child Deaths: A Qualitative Study of UK Parents- Joanna Garstang, Anna Pease, Karen Shaw, Jenna Spry, Gayle Routledge, Sara Kenyon
NCFRP - A Program Manual for Child Death Review Strategies to Better Understand Why Children Die & Taking Action to Prevent Child Deaths
NCFRP FATALITY REVIEW - CONSIDERATIONS FOR PLANNING AND PARTNERSHIPS
NCFRP - 10 steps to conducting an effective review handout
NCFRP - Access to Death Review Data: Research Opportunities to Save Children’s Lives
NCFRP - Assessment Tools for Fatality Review Teams
NCFRP-Building Relationships Between Fatality Review Teams and Schools
NCFRP - Conducting Effective CDR Meetings
NCFRP - CDR Roles of Team Members
NCFRP - Child Maltreatment Fatality Reviews - Learning together to improve systems that protect children and prevent maltreatment
NCFRP - CDR Defining Purpose Principles and Objectives Worksheet
External Resources
Past Congress Recaps
Vilnius Congress
Conveners of the Child Death Review Working Group
Fujiko Yamada, MD, PhD
ISPCAN Board Member & Director of Jaspcan JAPAN
Dr Fujiko Yamada currently holds the following positions:
- Vice President, Sangenkai Yamada Clinic of Internal Medicine and Gastroenterology
- President, Child First Japan (CFJ), a certified non-profit organization
- Member of Board of Directors, International Society for the Prevention of Child Abuse and Neglect (ISPCAN)
- Member of Board of Directors, Japanese Society for Prevention of Child Abuse and Neglect (JaSPCAN)
- Vice President, Japanese Medical Society on Child Abuse and Neglect (JaMSCAN)
- Adjunct Lecturer, Department of Midwifery, Showa Medical University
Her biography includes:
- 1986: Graduated from Tokyo Medical and Dental University (currently, Institute of Science Tokyo) School of Medicine, obtained medical license
- 1990: Established Yamada Clinic of Internal Medicine and Gastroenterology with her husband
- 1998: Established the Child Maltreatment Prevention Network (CMPN)
- 2015: CMPN opened “Children’s Advocacy Center Kanagawa (CAC Kanagawa)”.
- 2015: Awarded the degree of Doctor of Medicine (SBS/AHT Research) from Mie University Graduate School on March 25, 2015.
- 2015: CMPN changed the name to Child First Japan (CFJ)
- 2018: Appointed to a member of the Board of Directors of the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) in September
- 2024: CFJ opened “Mental and Physical Clinic for Children CAC Kanagawa”.
Vincent J. Palusci, MD, MS, FAAP, FAPSAC
Professor of Pediatrics and Forensic Medicine NYU Grossman School of Medicine
Vincent J. Palusci, MD, MS is Professor of Pediatrics and Forensic Medicine at NYU Grossman School of Medicine in New York City, USA. He has provided clinical care and training in general and child abuse pediatrics and has developed hospital-based programs to help families develop positive parenting and prevent child maltreatment. As a member of ISPCAN he has contributed to our World Perspectives on Child Abuse and has presented at a number of Congresses. Dr. Palusci has held leadership positions with the American Academy of Pediatrics, the American Professional Society on the Abuse of Children, and Michigan’s child death review program, chairing its fatality citizen review panel. Other service includes being editor in chief of the journal Child Maltreatment, board president for Prevent Child Abuse–New York, a board member of the Association of Professionals Solving the Abuse of Children (APSAC), and appointee to the American Board of Pediatrics. His research and publications have focused on child abuse fatality, medical practice and child maltreatment identification, reporting, and prevention.
Ayako Ishikura, MD
Board Member JaSPCAN (Japanese Society for Prevention of Child Abuse and Neglect) and JaMSCAN (Japanese Medical Society on Child Abuse and Neglect)
Ayako is a general pediatrician now working in Hakodate Central General Hospital, Hakodate city, Hokkaido, Japan. She was born in Japan and spent part of her childhood in the USA and France. She completed her studies at the Medical School of Tohoku University in 1996. She has been working in the hospital together with community organizations to support children and families with vulnerability. Since 2015 with the support of her hospital staff, she prepares bimonthly seminars (Child First Hakodate) related to child abuse and neglect focusing on how the community can cooperate to cultivate positive impact on children’s lives. She has prepared her hospital to be the medical center of the area’s SART (Sexual Assault Response Team) and helps connect children to the regional trauma therapist. She is also a central member of Hokkaido’s Child Death Review Model Project. She is a board member of JaSPCAN (Japanese Society for Prevention of Child Abuse and Neglect) and JaMSCAN (Japanese Medical Society on Child Abuse and Neglect), both country partners of ISPCAN. She is also the Chairperson of the International Activities Committee of JaSPCAN. Her specific interests include prevention and intervention of child abuse, connecting multiple community facilities.
Dr Joanna Garstang
University of Birmingham School of Nursing and Midwifery College of Medicine and Health
Dr Joanna Garstang is a Clinical Associate Professor of Child Protection at the University of Birmingham, Consultant Community Paediatrician and Designated Doctor for Child Death for Birmingham and Solihull. Her specialist areas are in safeguarding children, Child Death Review and Sudden Unexpected Death in Childhood. Her research has focusses on improving multi-agency working in safeguarding and preventable child mortality. Joanna has been part of the team conducting analyses of Local Child Safeguarding Practice Reviews.
Joanna led an NIHR study ‘Involving Parents and Staff in Learning from Child Deaths’, developing a Child Death Review toolkit with bereaved parents. She led a study ‘Improving Safeguarding Outcomes following adoption or Special Guardianship’, funded by the Nuffield Foundation. She is currently leading research on risks of vaping and infant death and improving care for families after sudden child death.
Joanna is Chair of the Association of Child Death Review Professionals, Chair of ISPID (International sudden infant and child death) and a Specialist Medical Advisor to the English National Child Mortality Database.
John Devaney, PhD
Centenary Chair of Social Work at the University of Edinburgh, United Kingdom.
John Devaney, PhD is the Centenary Chair of Social Work at the University of Edinburgh, United Kingdom. He is a qualified social worker, and worked for nearly twenty years in social work practice before moving into academia. His research interests relate to the impact of adversity in childhood across the life course, child maltreatment, domestic abuse, and evaluations of interventions.
He was previously the Chair of the British Association for the Study and Prevention of Child Abuse and Neglect, and was a member of the Safeguarding Board for Northern Ireland where he chaired the Case Management Review Panel, examining the death and serious injury of children through abuse and neglect.